Incorrect counts at shift change

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    Today I was working OT and when my relief came in my scrub nurse and I counted sponges, sutures ect. and found that our suture count was incorrect. We counted 18 sutures, 18 suture packs but 19 were written down. I went through the garbage and found 18 suture wrappers. I guess I made a mistake and wrote the wrong number down when I gave sutures up to the sterile field. The team was told about it and was happy with the search. I understand that this would make for an incorrect count, and that a report would need to be written up as things get lost. My problem, besides feeling bad that I left a report for the relieving nurse, is the scrub nurse seemed angry with me. I'm not perfect, it was a busy case, and I made a mistake. It happens.
    What would you all do in this situation?
    Lisa
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  3. 7 Comments so far...

  4. 1
    Hmmmmm... If you want a truly honest answer, I wouldn't have left this for someone else to deal with and I can understand people being a little upset that you left it to your relief to do the paperwork on this. I know it happens, and that's just one of those things, but you clean up your own mess in my book.
    RN Zeke likes this.
  5. 0
    So I appreciate your comments, and I to would normally do it myself and not leave it for the relief nurse, however there was still two hours to go in the case, and she insisted that I leave. She said their is too much time left in the case for me to write a report up and something else with the count could also go wrong. She had no problem with doing the report. It was the scrub nurse that seemed to be upset by the incorrect count. I understand that both of our names are going to be on the count sheet, and I do think that noting in the chart that the count was incorrect is something that must be done, but it was her attitude about it that aggravated me. Despite going through the garbage's, and doing multiple recounts, and agreeing to mark the count as incorrect she was still angry. I guess I was just venting about attitude.
  6. 1
    Lisa, I must say that I think that you did the right thing. In this day and age of "fiscal responsibility," any overtime is discouraged and maybe even penalized. Even for a good reason, like staying over to "clean up your own mess." You exhausted every effort to discover the origination of the error and reported off appropriately. You accepted ownership of the error. It happens. If you've never written something down wrong, you haven't been in the OR long enough. The patient would get an X-Ray no matter what and an incident report would be filled out no matter what. And as far as your scrub being angry at the error (excuse my language) but tough sh*t. It happens. I am certain that s/he has lost a needle or sponge or two in their lifetime. Perhaps it was a bad day for your scrub and not because of you.
    GadgetRN71 likes this.
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    Perhaps your scrub was angry at herself for getting an incorrect count? It takes two to tango/count, so the fault cannot solely be placed on you. I disagree with the previous post about fiscal responsibility. To me, patient safety is far more important than money and I think any OR manager would agree. Spending the appropriate amount of time to perform the counting procedure including documentation actually saves the hospital money because it prevents retained items. The relief nurse had no right to tell you to leave your own case against your better judgment. Also, it is not good technique to reconcile a needle count with the wrappers from the garbage. Needles should be counted by two (one must be an RN) members of the surgical team as they are visualized by both people, and any discrepancy will result in an incorrect count/operative search/xray (if needle(s) cannot be located/accounted for.) Even if you wrote a number down wrong and can't figure out how it happened... we're human, it happens; write your report and be on your way.
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    I concur that reconciliation against wrappers is a bad idea. I did not mean to say the fiscal responsibility thing is a VALID reason to leave, just a reason management uses to enforce time usage. However, a bad count is a bad count. Once an item is lost, staying to finish the procedure serves no useful purpose. However, as the primary nurse involved at the time of the discrepancy, a report should have been filled out by that (the primary) nurse.
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    I have added wrong before on my count sheet, and have been in exactly the same situation you describe. Now I write the needle count up on a whiteboard so that the scrub can see it too. I also record counts on the designated count sheet near my desk. It may seem like double the work, but it really helps when the scrub nurse can clearly see the needle counts and correct my math if I add wrong or if I add too many/too few needles. This way BOTH of you are in agreement.
  10. 0
    This is one of the reasons I save the wrappers to anything I add after the initial count. Added an 8 pack of pop-off ethibond? Wrapper goes on the desk by the computer. I also write under the added sutures what it was- if I add a 6-0 prolene, under the "2" I'll write "6-0 P" just so I know what it was and then I can correlate wrappers to my count sheet. When the initial count is 53 and we finish with over 300 needles, it's nice to know I have something to make sure the numbers match up!


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